Skip to main content
SpringerLink
Log in

Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients

  • Original Article
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Introduction

Patient prosthesis mismatch is known to alter post-operative remodeling of left ventricle adversely in aortic stenosis patients. An indexed orifice area of 0.85 is considered as conventional cutoff for patient prosthesis mismatch based on hemodynamic principles. Many patients have smaller annulus and annulus enlargement techniques may be required to avoid this benchmark which complicates the surgery.

Aims and objectives

To determine incidence of patient prosthesis mismatch (PPM) in our population, to assess left ventricle (LV) regression and impact of indexed effective orifice area on LV regression, and to determine a minimum acceptable cut off indexed orifice area that will result in LV regression.

Materials and methods

A single-center retrospective observational study of all patients who underwent aortic valve replacement surgery for severe aortic stenosis between July 2015 and December 2015 was conducted. Patients who underwent concomitant revascularization or other valve surgery were excluded. Data regarding conventional risk factors for PPM, valve type, and indexed orifice area as well as pre-operative and late post-operative LV mass were collected.

Observations

Thirty-seven of the 91 patients satisfied inclusion criteria. All patients had significant regression in LV mass. The incidence of PPM was 68%. Regression of indexed left ventricular mass showed a positive correlation of with indexed effective orifice area of the prosthetic valve. The correlation coefficient is + 0.48 (95% CI 0.18–0.698). Left ventricular mass regression was significantly higher in patients with indexed effective orifice area more than 0.75 (68.89 ± 29 vs 122.55 ± 58.84, p = 0.028). Relative left ventricular regression also was significantly higher in patients with an indexed effective orifice area more than 0.75 (39.53 ± 13.13 vs 49.73 ± 15.56, p = 0.022). There is a positive correlation between left ventricular regression and the reduction in mean gradient achieved by valve replacement. The correlation coefficient was + 0.35 (95% CI 0.03–0.61).

Conclusions

The incidence of PPM was found to be comparable to literature. There is a positive correlation between left ventricular regression and indexed effective orifice area of the prosthetic valve. Left ventricular regression was significantly higher in patients with an indexed effective area more than 0.75. This can be considered as criteria for significant PPM in study population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Nathaniel S, Saligram S, Innasimuthu AL. Aortic stenosis: an update. World J Cardiol. 2010;2:135–9.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J. 2014;66:320–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Apostolakis E, Baikoussis NG, Papakonstantinou NA, Goudevenos J. Patient-prosthesis mismatch and strategies to prevent it during aortic valve replacement. Hell J Cardiol. 2011;52:41–51.

    Google Scholar 

  4. Horstkotte D, Loogen F. The natural history of aortic valve stenosis. Eur Heart J. 1988;9:E57–64.

    Article  Google Scholar 

  5. Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Left ventricular mass and incidence of coronary heart disease in an elderly cohort: the Framingham Heart Study. Ann Intern Med. 1989;110:101–7.

    Article  CAS  PubMed  Google Scholar 

  6. Mohty D, Dumesnil JG, Echahidi N, et al. Impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement: influence of age, obesity and left ventricular dysfunction. J Am Coll Cardiol. 2009;53:39–47.

    Article  PubMed  Google Scholar 

  7. Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation. 1978;58:20–4.

    Article  CAS  PubMed  Google Scholar 

  8. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart. 2006;92:1022–9.

    Article  CAS  PubMed  Google Scholar 

  9. Dumesnil JG, Honos GN, Lemieux M, Beauchemin J. Validation and applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography. J Am Coll Cardiol. 1990;16:637–43.

    Article  CAS  PubMed  Google Scholar 

  10. Dumesnil JG, Yoganathan AP. Valve prosthesis hemodynamics and the problem of high transprosthetic pressure gradients. Eur J Cardiothorac Surg. 1992;6:S34–8.

    Article  PubMed  Google Scholar 

  11. Bonderman D, Graf A, Kammerlander AA, et al. Factors determining patient-prosthesis mismatch after aortic valve replacement - a prospective cohort study. PLoS One. 2013;8:e81940.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Devereux RB, Alonso DR, Lutas EM, et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986;57:450–8.

    Article  CAS  Google Scholar 

  13. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440–63.

    Article  Google Scholar 

  14. Pibarot P, Dumesnil JG. The relevance of prosthesis-patient mismatch after aortic valve replacement. Nat Clin Pract Cardiovasc Med. 2008;5:764–5.

    Article  PubMed  Google Scholar 

  15. Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol. 2000;36:1131–41.

    Article  CAS  PubMed  Google Scholar 

  16. Walther T, Rastan A, Falk V, et al. Patient prosthesis mismatch affects short- and long-term outcomes after aortic valve replacement. Eur J Cardiothorac Surg. 2006;30:15–9.

    Article  PubMed  Google Scholar 

  17. Kohsaka S, Mohan S, Virani S, et al. Prosthesis-patient mismatch affects long-term survival after mechanical valve replacement. J Thorac Cardiovasc Surg. 2008;135:1076–80.

    Article  PubMed  Google Scholar 

  18. Howell NJ, Keogh BE, Ray D, et al. Patient-prosthesis mismatch in patients with aortic stenosis undergoing isolated aortic valve replacement does not affect survival. Ann Thorac Surg. 2010;89:60–4.

    Article  PubMed  Google Scholar 

  19. Howell NJ, Keogh BE, Barnet V, et al. Patient-prosthesis mismatch does not affect survival following aortic valve replacement. Eur J Cardiothorac Surg. 2006;30:10–4.

    Article  PubMed  Google Scholar 

  20. Hong S, Yi GJ, Youn YN, Lee S, Yoo KJ, Chang BC. Effect of the prosthesis-patient mismatch on long-term clinical outcomes after isolated aortic valve replacement for aortic stenosis: a prospective observational study. J Thorac Cardiov Surg. 2013;146:1098–104.

    Article  PubMed  Google Scholar 

  21. Fuster RG, Montero Argudo JA, Albarova OG, et al. Patient-prosthesis mismatch in aortic valve replacement: really tolerable? Eur J Cardiothorac Surg. 2005;27:441–9.

    Article  PubMed  Google Scholar 

  22. Ruel M, Al-Faleh H, Kulik A, Chan KL, Mesana TG, Burwash IG. Prosthesis-patient mismatch after aortic valve replacement predominantly affects patients with preexisting left ventricular dysfunction: effect on survival, freedom from heart failure, and left ventricular mass regression. J Thorac Cardiovasc Surg. 2006;131:1036–44.

    Article  PubMed  Google Scholar 

  23. Kaminishi Y, Misawa Y, Kobayashi J, et al. Patient-prosthesis mismatch in patients with aortic valve replacement. Gen Thorac Cardiovasc Surg. 2013;61:274–9.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Medalion B, Blackstone EH, Lytle BW, White J, Arnold JH, Cosgrove DM. Aortic valve replacement: is valve size important? J Thorac Cardiovasc Surg. 2000;119:963–74.

    Article  CAS  PubMed  Google Scholar 

  25. LaPar DJ, Ailawadi G, Bhamidipati CM, et al. Small prosthesis size in aortic valve replacement does not affect mortality. Ann Thorac Surg. 2011;92:880–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sportelli E, Regesta T, Salsano A, et al. Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients? J Cardiovasc Med. 2016;17:137–43.

    Article  Google Scholar 

  27. Hernández-Vaquero D, Llosa JC, Díaz R, et al. Impact of patient-prosthesis mismatch on 30-day outcomes in young and middle-aged patients undergoing aortic valve replacement. J Cardiothorac Surg. 2012;7:46.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Hanayama N, Christakis GT, Mallidi HR, et al. Patient prosthesis mismatch is rare after aortic valve replacement: valve size may be irrelevant. Ann Thorac Surg. 2002;73:1822–9.

    Article  PubMed  Google Scholar 

  29. Kato Y, Suehiro S, Shibata T, Sasaki Y, Hirai H. Impact of valve prosthesis-patient mismatch on long-term survival and left ventricular mass regression after aortic valve replacement for aortic stenosis. J Card Surg. 2007;22:314–9.

    Article  PubMed  Google Scholar 

  30. Guo L, Zheng J, Chen L, et al. Impact of prosthesis–patient mismatch on short-term outcomes after aortic valve replacement: a retrospective analysis in East China. J Cardiothorac Surg. 2017;12:42.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Head SJ, Mokhles MM, Osnabrugge RLJ, et al. The impact of prosthesis–patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27 186 patients with 133 141 patient-years. Eur Heart J. 2012;33:1518–29.

    Article  PubMed  Google Scholar 

  32. Chen J, Lin Y, Kang B, Wang Z. Indexed effective orifice area is a significant predictor of higher mid- and long-term mortality rates following aortic valve replacement in patients with prosthesis-patient mismatch. Eur J Cardiothorac Surg. 2014;45:234–40.

    Article  PubMed  Google Scholar 

  33. Dayan V, Vignolo G, Soca G, Paganini JJ, Brusich D, Pibarot P. Predictors and outcomes of prosthesis-patient mismatch after aortic valve replacement. JACC Cardiovasc Imaging. 2016;9:924–33.

    Article  PubMed  Google Scholar 

  34. Joshi SS, Ashwini T, George A, Jagadeesh AM. Patient prosthesis mismatch after aortic valve replacement: an Indian perspective. Ann Card Anaesth. 2016;19:84–8.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Singh A, Sinha VK, Khandekar J, Agrawal N, Patwardhan A, Khandeparkar J. Left ventricular mass regression following aortic valve replacement with mechanical valves. Indian J Thorac Cardiovasc Surg. 2006;22:121–5.

    Article  Google Scholar 

  36. Dare AJ, Veinot JP, Edwards WD, Tazelaar HD, Schaff HV. New observations on the etiology of aortic valve disease: a surgical pathologic study of 236 cases from 1990. Hum Pathol. 1993;24:1330–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Mr. Kulwant Singh Kappor, MSc (Biostatistics) for his help with the statistical analysis.

Author information

Authors and Affiliations

  1. Department of Cardio Vascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, 695011, India

    Abid Iqbal, Varghese Thomas Panicker & Jayakumar Karunakaran

Authors
  1. Abid Iqbal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Varghese Thomas Panicker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jayakumar Karunakaran
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Abid Iqbal.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical issues

Ethical approval with waiver of consent was obtained from Institutional Ethics Committee prior to commencement of study.

Additional information

Discussant

Prof Milind Hote,

Professor, CTVS,

All India Institute of Medical Sciences, New Delhi.

Q1. It is an interesting study that seeks to look at the issue of PPM from another angle based on the conclusion statement “LV mass regression was significantly higher in patients with iEOA more than 0.75. This can be considered as criteria for significant PPM in study population”.

The study proposes to use LV mass regression as the judging criteria; compared to the conventional use of iEOA. So do the authors mean the patients in whom we implant prosthetic valves with 0.75 iEOA, these patients are NOT LIKELY to have any disabling symptoms in the immediate term and long term?.

Ans.: The outcome measured in our study is the extent of LV regression following AVR and we observe that LV regression in patients with iEOA between 0.75 and 0.85 is comparable to that in patients with iEOA more than 0.85, the conventional cut off for PPM. This in turn is significantly higher than those with iEOA less than 0.75. Since the pathophysiology in AS is closely associated with LV hypertrophy, the risk of developing disabling symptoms in patients with iEOA between 0.75 and 0.85 should be equal to those with iEOA more than 0.85.

Q2. There are conflicting reports available in literature on correlation between PPM and mortality. Some series say the mortality is increased, others deny the same ( no effect/equivocal effect ), and there is a recent report to the contrary also –Ana Kadkhodayan et al in“ Structural Heart” journal, 2017 issue, wherein they compared the 30 day mortality and LV mass regression between 2 groups ( Surgical AVR vs TAVR ). They found that group with HIGHER LV mass regression had significantly HIGHER 30 day mortality.

What in your estimate, would be the impact of using iEOA of 0.75 on long term mortality?.

Ans.: We had zero mortality during the duration of our study. Hence, we cannot project any estimates regarding long term survival solely on the basis of this study.

In the study of Kadkhodayan et al which compared outcome of surgical AVR with transcatheter AVR, mean age of patients was 80, with 72% having CAD while our population is significantly younger with lesser co-morbidities. Moreover, the authors themselves have attributed this anomalous result to difference in geometrical factors rather than actual difference in LV mass. So it may not be prudent to compare these results directly.

Q3. Do the authors recommend a larger study ( the study population is small in the present study, n=37), for the readers to discern better the pros and cons of using conventional iEOA (0.85 vs 0.75) for their patients. If yes, what should be the design of such a study?

Ans.: A larger prospective observational study minimizing observer variability in echocardiographic measurements should be performed to ratify our observations. A randomized controlled trial may be considered in patients with smaller aortic roots, where AVR can achieve an iEOA >0.75, but an aortic root enlargement procedure is required to ensure iEOA >0.85.

Q4. PPM is common (20-70 %) in world literature, following AVR in Aortic stenosis patients, your take?.

Ans.: PPM is not uncommon, nor is PPM fully avoidable. Even with root enlargement procedures, a maximum of 2 size increment only can be achieved. Patients with higher BSA and small roots are always at risk of developing PPM. Apparently, many surgeons prefer PPM rather than doing complex root enlargement procedures.

Q5. LV regression occurs in all; more in patients with no PPM; less regression is seen in patients having PPM. These 2 points are pretty well established. Some papers say that morbidity – mortality is more if we see the subset of patients having reduced EF. (Ruel M, Al-Faleh H, Kulik A, Chan KL, Mesana TG, Burwash IG. J Thorac Cardiovasc Surg. 2006 May;131(5):1036-44).

Would the authors suggest adding correlation with preoperative EF in their next study group of patients?

Ans.: Yes. Since we did not observe any mortality, it would have been irrelevant in this study. But in any further study, this should be considered as well.

Q6. Rahimtoola gave a very simple and elegant definition of PPM – If prosthetic valve area is less than natural area, (0.85), it qualifies as PPM. His onus was on suggesting that the abnormal hemodynamics that will occur as a result of PPM, are likely to cause morbidity and mortality. Literature is equivocal about the true correlation between PPM – LV regression – resulting patient morbidity & mortality. So why should we shift the goalpost of defining PPM from 0.85 to 0.75? Are we not recommending incomplete surgery?.

Ans.: Original benchmark of PPM is based on theoretical predictions and hemodynamic calculations. We on the other hand have attempted to assess the adequacy of valve area based on LV regression. LV regression is the most important quantifiable parameter which is believed to be capable of influencing clinical outcome after AVR.

Most of the systems in human body come with a level of redundancy and exact replication of the original iEOA may not be necessary to achieve an acceptable clinical outcome.

Q7. Why the observed regression is more in some patients and less in others for the same iEOA? Do the authors think that there is some genetic variability in the degree of regression that may occur in a patient after say a 50 mm Hg reduction in valve gradient?.

Ans.: There can be other confounding variables including genetic variability, hypertension and use of medications like ACE inhibitors that could have influenced LV regression. The study can be repeated in a bigger population and the data can be subjected to multivariate analysis to detect these factors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Iqbal, A., Panicker, V.T. & Karunakaran, J. Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients. Indian J Thorac Cardiovasc Surg 35, 6–14 (2019). https://doi.org/10.1007/s12055-018-0706-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12055-018-0706-3

Keywords

Search

Navigation